NLE Psychiatric Disorders — Substance Use and Addictive DisordersRevision Notes

Exam Tips

• NLE items will present a scenario and ask you to differentiate tolerance vs. dependence vs. addiction — memorize the definitions precisely.
• Any scenario involving a patient on chronic opioids for cancer pain who develops withdrawal when doses are held is describing DEPENDENCE, not addiction.
• When you see 'codependency' in an answer choice, look for enabling behaviors — calling in sick for the user, hiding alcohol, making excuses.

Key Points

• Tolerance, physical dependence, and addiction are three DIFFERENT concepts — confusing them is the most common NLE error in this chapter.
• Tolerance = physiologic change; more drug is needed for the same effect. This is neuroadaptation, NOT addiction.
• Physical dependence = the body has adapted so that STOPPING the drug causes a withdrawal syndrome. A post-operative patient on opioids for pain can be physically dependent WITHOUT being addicted.
• Addiction (Substance Use Disorder) = compulsive use + craving + continued use DESPITE harm. This is the behavioral/psychological component.
• Withdrawal = the cluster of symptoms that appear when a substance is reduced or stopped after chronic use.
• Intoxication = the reversible, substance-specific syndrome from RECENT use.
• Codependency = an enabling relationship pattern common in family members of substance users.
• Dual diagnosis = co-occurring substance use disorder AND another psychiatric illness (e.g., major depression + alcohol use disorder).
• Confabulation = fabricating memories to fill gaps — a hallmark of Korsakoff's psychosis.
• Enabling = behaviors by family or friends that allow the substance user to continue using without facing full consequences.

Definitions

Section Title

1. Core Terminology — Getting the Definitions Right

Common Mistakes

• Equating physical dependence with addiction — they are separate phenomena.
• Thinking tolerance means the patient is 'abusing' the medication — tolerance is a normal physiologic adaptation.
• Forgetting that dual diagnosis requires treatment of BOTH conditions, not just the substance use.

Exam Tips

• The NLE loves to ask: 'A patient admitted for alcohol withdrawal is now confused, agitated, with a temperature of 39.5°C, HR 130, and reports seeing insects on the ceiling. What stage is this?' Answer: DELIRIUM TREMENS (48–72 h).
• If an item asks about the FIRST action for a patient with DTs — always choose monitoring vital signs and ensuring a safe environment, then administering benzodiazepines as ordered.
• When asked about which benzodiazepine for a patient with liver disease — answer is LORAZEPAM.
• A room for a patient with DTs should be: quiet, well-lit (to reduce misperceptions), with fall precautions in place.
• CIWA-Ar guides SYMPTOM-TRIGGERED dosing — this is safer than fixed-schedule dosing.

Key Points

• Alcohol is a CNS DEPRESSANT. Intoxication depresses the CNS; withdrawal produces a rebound CNS EXCITATION — this is why withdrawal is dangerous.
• Priority danger in INTOXICATION: respiratory depression and aspiration — protect the airway first.
• The alcohol withdrawal timeline is one of the most heavily tested sequences on the NLE — memorize it by hours.
• 6–12 hours: early withdrawal — tremors, anxiety, nausea, insomnia, sweating, tachycardia, hypertension.
• 12–24 hours: alcoholic hallucinosis — visual or tactile hallucinations with CLEAR sensorium (patient knows what is real).
• 24–48 hours: withdrawal seizures ('rum fits') — typically generalized tonic-clonic.
• 48–72 hours: Delirium Tremens (DTs) — the MOST SEVERE and MOST DANGEROUS stage.
• Delirium Tremens hallmarks: severe autonomic hyperactivity (marked tachycardia, hypertension, hyperthermia, profuse diaphoresis), profound confusion and disorientation, agitation, and vivid terrifying hallucinations (classically visual and tactile — 'bugs crawling on skin').
• DTs = MEDICAL EMERGENCY with significant mortality if untreated.
• Treatment of choice for alcohol withdrawal and DTs: BENZODIAZEPINES (diazepam, lorazepam, chlordiazepoxide).
• Lorazepam is PREFERRED when liver function is impaired because it does not require hepatic oxidation.
• CIWA-Ar score guides symptom-triggered benzodiazepine dosing.
• ALWAYS give THIAMINE BEFORE GLUCOSE in alcoholic patients — this is a classic NLE safety question.
• Seizure precautions are mandatory during the withdrawal period.

Definitions

Section Title

2. Alcohol Use Disorder — Intoxication to Delirium Tremens

Common Mistakes

• Mixing up the timeline — especially placing DTs at 24–48 hours instead of 48–72 hours.
• Forgetting that alcoholic hallucinosis has a CLEAR sensorium — unlike DTs where confusion is profound.
• Giving glucose before thiamine — this can precipitate or worsen Wernicke's encephalopathy.
• Choosing sedative-hypnotics other than benzodiazepines as first-line — benzodiazepines are always first-line.
• Forgetting seizure precautions once the patient is admitted for withdrawal management.

Exam Tips

• Classic NLE stem: 'An alcoholic patient is brought to the ER in semi-consciousness. The nurse prepares to administer IV D5W. What should the nurse do FIRST?' Answer: Administer thiamine BEFORE the IV glucose.
• Wernicke's = 3 C's: Confusion, Cross-eyes (ophthalmoplegia), Coordination loss (ataxia).
• Korsakoff's = Amnesia + confabulation — the patient cannot make new memories.
• If an item says the patient 'tells different stories about the same event' or 'cannot recall what happened yesterday' in an alcoholic patient — think Korsakoff's.

Key Points

• Caused by THIAMINE (Vitamin B1) deficiency from chronic alcohol use (poor dietary intake + impaired absorption).
• Two-phase disorder: Wernicke's (acute, reversible) → Korsakoff's (chronic, largely irreversible).
• Wernicke's Encephalopathy TRIAD: Confusion + Ophthalmoplegia (eye movement abnormalities/nystagmus) + Ataxia (unsteady gait).
• Wernicke's is a medical emergency — treated with IMMEDIATE IV/IM thiamine.
• Korsakoff's Psychosis: profound short-term memory loss + confabulation. The patient cannot form new memories and fills gaps with fabricated stories.
• Korsakoff's is largely IRREVERSIBLE — this is why preventing Wernicke's with early thiamine is critical.
• THE GOLDEN RULE: Give THIAMINE BEFORE GLUCOSE in any alcoholic patient. If glucose is given first, the remaining thiamine stores are consumed and Wernicke's can be precipitated or worsened.
• Nursing care for Korsakoff's: reality orientation, safe environment, consistent routine, non-judgmental approach to confabulation (do not argue or reinforce).

Definitions

Section Title

3. Wernicke-Korsakoff Syndrome — Thiamine Deficiency Emergency

Common Mistakes

• Giving IV dextrose (glucose) BEFORE thiamine — this is a critical safety error.
• Confusing the two phases: Wernicke's = acute and reversible; Korsakoff's = chronic and irreversible.
• Thinking confabulation means the patient is lying — it is an unconscious filling of memory gaps.
• Forgetting that ataxia in Wernicke's is a FALL RISK requiring immediate safety precautions.

Exam Tips

• NLE scenario: 'Patient with alcoholism and liver cirrhosis is in withdrawal. Which benzodiazepine?' Answer: LORAZEPAM.
• NLE scenario: 'A patient on disulfiram uses an alcohol-based mouthwash. What signs does the nurse expect?' Answer: Flushing, headache, nausea, tachycardia, hypotension.
• NLE scenario: 'A heroin user is brought in unconscious, respiratory rate 4 per minute, pinpoint pupils.' Priority intervention? Administer NALOXONE IV; then prepare for repeat dosing.
• Naltrexone ≠ Naloxone: Naltrexone is taken orally for relapse prevention (opioids AND alcohol); Naloxone is used for acute overdose reversal.

Key Points

• BENZODIAZEPINES are first-line treatment for BOTH alcohol withdrawal and sedative-hypnotic withdrawal.
• Diazepam (Valium), Lorazepam (Ativan), Chlordiazepoxide (Librium) — all act as CNS depressants, substituting for alcohol's effect and allowing safe tapering.
• LORAZEPAM is preferred in liver disease (does not require hepatic oxidative metabolism — excreted by direct glucuronidation).
• Monitor for: oversedation, respiratory depression, and paradoxical agitation with benzodiazepines.
• THIAMINE (Vitamin B1): given IV/IM before glucose to prevent/treat Wernicke's encephalopathy.
• MAGNESIUM replacement: hypomagnesemia lowers seizure threshold — replete as ordered.
• DISULFIRAM (Antabuse): aversion therapy for maintaining abstinence. Blocks alcohol metabolism → acetaldehyde accumulates → severe reaction.
• Disulfiram reaction: flushing, throbbing headache, nausea/vomiting, tachycardia, hypotension, dyspnea — can be fatal in severe cases.
• Patient must avoid ALL sources of alcohol: mouthwash, cough syrup, aftershave, cologne, vinegar, sauces, cooking wine.
• The reaction can occur up to 2 WEEKS after the last dose of disulfiram.
• NALTREXONE: opioid antagonist that reduces alcohol craving; also used in opioid use disorder.
• ACAMPROSATE: reduces cravings and PAWS (post-acute withdrawal syndrome) by modulating glutamate; useful for maintaining abstinence.
• NALOXONE (Narcan): opioid antagonist — reverses opioid overdose rapidly. SHORT-ACTING — may need repeat doses; can precipitate acute withdrawal.
• METHADONE and BUPRENORPHINE: used for opioid maintenance therapy — reduce cravings and illicit use under medical supervision.
• CLONIDINE: alpha-2 agonist — reduces autonomic symptoms of opioid withdrawal (not the craving).
• FLUMAZENIL: reverses benzodiazepine overdose — use with CAUTION as it can precipitate seizures in benzodiazepine-dependent patients.

Definitions

Section Title

4. Pharmacology — Alcohol Withdrawal and Rehabilitation Drugs

Common Mistakes

• Choosing any benzodiazepine without considering liver function — use lorazepam when liver disease is present.
• Forgetting to teach patients about hidden alcohol sources with disulfiram (mouthwash, aftershave, cough syrup).
• Thinking naloxone is long-acting — it is SHORT-ACTING; the patient must be monitored for re-sedation.
• Using flumazenil carelessly — it can trigger severe seizures in benzodiazepine-dependent patients.
• Confusing naltrexone (for cravings/relapse prevention) with naloxone (for acute overdose reversal).

Exam Tips

• Pupils are a high-yield differentiator: PINPOINT = opioid intoxication; DILATED = stimulant intoxication OR opioid withdrawal.
• If an NLE question asks about a patient with shabu intoxication who is combative, hyperthermic, and having hallucinations — priority is safety and temperature management.
• Remember: alcohol/sedative withdrawal = FATAL risk; opioid withdrawal = NOT fatal but extremely uncomfortable.
• Stimulant withdrawal crash + depression = SUICIDE RISK — always include suicide precautions in the nursing care plan.

Key Points

• OPIOID INTOXICATION/OVERDOSE TRIAD: Pinpoint (miotic) pupils + Respiratory depression + Decreased LOC. Priority: AIRWAY — administer naloxone, support breathing.
• Opioid withdrawal is INTENSELY uncomfortable but NOT life-threatening (unlike alcohol/sedative withdrawal): dilated pupils, yawning, lacrimation, rhinorrhea, muscle aches, abdominal cramping, diarrhea, piloerection ('goosebumps' — origin of 'cold turkey').
• STIMULANTS (cocaine, amphetamines, methamphetamine/'shabu'): CNS EXCITANTS. Intoxication produces the OPPOSITE of opioids.
• Stimulant intoxication: euphoria, hypervigilance, DILATED pupils, tachycardia, hypertension, hyperthermia, agitation, seizures, dysrhythmias, MI, stroke, and psychosis with paranoia.
• In the Philippines, methamphetamine ('shabu') is the most prevalent stimulant — relevant in NCM community health and psychiatric contexts.
• Stimulant withdrawal ('crash'): intense fatigue, hypersomnia, depression, increased appetite, and STRONG craving. KEY CONCERN: HIGH SUICIDE RISK during the crash phase.
• Management of stimulant intoxication: calm environment, control hyperthermia and hypertension, monitor for seizures and cardiac dysrhythmias — treatment is largely SUPPORTIVE.
• SEDATIVE-HYPNOTICS (benzodiazepines, barbiturates): CNS DEPRESSANTS like alcohol.
• Sedative-hypnotic withdrawal closely MIRRORS alcohol withdrawal — can cause SEIZURES and DELIRIUM and is potentially FATAL.
• NEVER stop sedatives or alcohol abruptly — always taper gradually under medical supervision.
• Barbiturate overdose has a narrow therapeutic-to-lethal dose margin — especially dangerous.
• Flumazenil reverses benzodiazepine overdose but can precipitate seizures — use with extreme caution.
• Key comparison: Opioid withdrawal = miserable but not fatal; Alcohol/sedative withdrawal = can be FATAL.

Definitions

Section Title

5. Opioid, Stimulant, and Sedative-Hypnotic Use Disorders

Common Mistakes

• Thinking opioid withdrawal is life-threatening — it is not (unlike alcohol/sedative withdrawal).
• Forgetting to assess for SUICIDE RISK during stimulant withdrawal (the crash).
• Giving flumazenil to a chronic benzodiazepine user without recognizing the seizure risk.
• Mixing up pupil sizes: opioid overdose = PINPOINT (miosis); stimulant/opioid withdrawal = DILATED (mydriasis).

Exam Tips

• NLE scenario: 'The patient says he can stop drinking any time he wants and doesn't have a problem.' This is DENIAL. The nurse's best response is to provide factual, non-confrontational information about the effects of alcohol and reflect back the impact on his life.
• When an NLE item asks about priority nursing diagnosis for a patient in DTs — choose Risk for Injury (physiologic safety first, per Maslow).
• A firm, consistent, non-judgmental approach is the key therapeutic stance — never judgmental, never enabling.
• 12-step programs (AA, NA) are the gold standard for long-term maintenance — know their purpose.

Key Points

• The THREE phases of recovery: Detoxification (acute withdrawal management) → Rehabilitation (skills, relapse prevention, restructuring) → Maintenance (long-term support).
• DETOXIFICATION safely manages withdrawal — it is NOT treatment of addiction itself, only the first step.
• REHABILITATION builds coping skills, identifies triggers, practices refusal skills, and restructures lifestyle.
• MAINTENANCE: ongoing support through 12-step programs — Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Al-Anon (for families).
• The therapeutic nursing stance is FIRM, CONSISTENT, and NON-JUDGMENTAL — accept the person, set limits on behavior.
• CONFRONT DENIAL: substance users commonly use denial, rationalization, and manipulation as defenses — the nurse must address these directly but without hostility.
• AVOID ENABLING: do not take over the patient's responsibilities, do not make excuses, do not protect them from the natural consequences of their behavior.
• Encourage the patient to TAKE RESPONSIBILITY for their own behavior and recovery.
• Identify RELAPSE TRIGGERS: people, places, and things associated with past use — stress, social cues, emotional states.
• CODEPENDENCY in families: refer to Al-Anon, family therapy; teach the difference between support and enabling.
• Priority NANDA nursing diagnoses in substance use disorders: Risk for Injury (withdrawal complications), Ineffective Denial, Ineffective Coping, Imbalanced Nutrition: Less Than Body Requirements, Disturbed Sensory Perception (hallucinations), Self-Care Deficit.
• Maslow prioritization: physiologic safety (withdrawal seizures, respiratory depression) ALWAYS comes before psychological/psychosocial needs.

Definitions

Section Title

6. Nursing Management — Rehabilitation and Therapeutic Approach

Common Mistakes

• Being too sympathetic and enabling — the nurse must be compassionate but firm, not a rescuer.
• Ignoring denial — it must be confronted gently but directly.
• Prioritizing psychosocial needs over physiologic safety (e.g., addressing denial before managing withdrawal seizures).
• Forgetting to involve the family and address codependency in the care plan.

Exam Tips

• NLE will ask: 'Which agency is responsible for POLICY on dangerous drugs?' Answer: DANGEROUS DRUGS BOARD (DDB).
• NLE will ask: 'Which agency ENFORCES drug laws in the Philippines?' Answer: PDEA.
• Remember: RA 9165 does NOT treat all drug users as criminals — the voluntary submission program reflects a public health approach to drug dependence.
• Confidentiality of drug treatment records protects the patient — nurses cannot disclose this information without the patient's consent or a court order.

Key Points

• RA 9165 = Comprehensive Dangerous Drugs Act of 2002 — the PRIMARY Philippine law governing dangerous drugs.
• Created the DANGEROUS DRUGS BOARD (DDB) as the POLICY-MAKING body.
• Created the PHILIPPINE DRUG ENFORCEMENT AGENCY (PDEA) as the IMPLEMENTING and ENFORCEMENT agency.
• RA 9165 recognizes the drug dependent as a person needing TREATMENT AND REHABILITATION, not only punishment.
• Provides for a VOLUNTARY SUBMISSION PROGRAM — drug dependents may voluntarily submit themselves for treatment/rehabilitation.
• Court-ordered rehabilitation is also available as an alternative to imprisonment for certain drug offenses.
• Mandates CONFIDENTIALITY of records of drug-dependent patients undergoing treatment and rehabilitation.
• Provides for MANDATORY DRUG TESTING in specified populations: students, employees, government officials, members of the military and police.
• Penalizes importation, sale, manufacture, possession, and use of dangerous drugs.
• Nurses participate in: drug screening, treatment and rehabilitation, health education, prevention programs, and mandatory reporting obligations within this framework.
• RA 9173 (Philippine Nursing Act of 2002): registered nurses must practice within legal and ethical standards — this includes maintaining confidentiality of patient records (consistent with RA 9165) and providing non-discriminatory care to drug-dependent patients.

Definitions

Section Title

7. Philippine Legal Framework — RA 9165 (Comprehensive Dangerous Drugs Act of 2002)

Common Mistakes

• Confusing DDB (policy) with PDEA (enforcement) — they are different agencies with different functions.
• Thinking RA 9165 only penalizes users — it also provides for treatment, rehabilitation, and voluntary submission.
• Forgetting the confidentiality clause — patient records in drug rehabilitation are protected by law.
• Mixing up RA 9165 (Dangerous Drugs Act) with RA 9173 (Nursing Act) — both are relevant to nursing practice.